RESUMEN
BACKGROUND: Guidelines recommend screening for transthyretin amyloid cardiomyopathy (ATTR-CM) after age 65 years, yet some patients are diagnosed earlier. OBJECTIVES: The purpose of this study was to compare the proportion, clinical characteristics, and prognosis of wild-type ATTR-CM diagnosed ≤65 years (ATTRwt-Yy) with those diagnosed >65 years (ATTRwt-O). METHODS: Data from the HEAR (Healthcare European Amyloidosis Registry), a multicenter, noninterventional, longitudinal registry, were analyzed. Patients were categorized by age at diagnosis: ATTRwt-Yy (≤65 years) and ATTRwt-O (>65 years). ATTRwt-O patients were further classified by onset of first cardiac symptom: ATTRwt-Oy (≤65 years) and ATTRwt-Oo (>65 years). RESULTS: From July 2021 to May 2024, 3,980 ATTR patients were enrolled; 1,417 had ATTRwt-CM with documented symptom onset. Among them, 67 (4.7%) were ATTRwt-Yy, 111 (7.8%) ATTRwt-Oy, and 1,239 (87.4%) ATTRwt-Oo. Diagnostic delays were 0.65, 20.58, and 0.77 years, respectively (P < 0.001). Heart failure signs at presentation were seen in 34.9% of ATTRwt-Yy, 8.1% of ATTRwt-Oy, and 30.2% of ATTRwt-Oo (P < 0.001). ATTRwt-Yy patients had more extracardiac manifestations, notably osteoarticular disease, whereas rhythm disturbances predominated in ATTRwt-Oy. Median follow-up from diagnosis was 36.2, 23.6, and 22.4 months, respectively. ATTRwt-Yy patients had better survival after diagnosis compared to ATTRwt-O patients. CONCLUSIONS: ATTRwt-CM diagnosed before 65 years shows a distinct phenotype highlighting the need for tailored diagnostic and management strategies.
RESUMEN
BACKGROUND: Calcified mitral valve disease (CMVD) is an increasingly recognized condition associated with specific management challenges. MITRACURE, a large, multicenter, observational registry conducted in France and Canada, provides real-world insights into the characteristics and outcomes of patients with CMVD undergoing MV surgery. METHODS: Among the 3522 patients included in MITRACURE, patients identified with CMVD were matched 4:1 for age, sex, and concomitant procedures with patients with myxomatous MV disease. RESULTS: Sixty patients (2%) with CMVD were matched to 240 with myxomatous MV disease. Compared with the myxomatous cohort, CMVD patients had a greater burden of cardiovascular risk factors, more comorbidities, and a more advanced presentation, with 70% vs 52% in New York Heart Association class III or IV (P = 0.01). In-hospital mortality and major complication rates (composite of death, cardiogenic shock/low cardiac output requiring inotropes, acute renal failure requiring dialysis, and stroke or transient ischemic attack) were significantly higher in CMVD than in myxomatous patients (20% vs 4% and 38% vs 20%, both P < 0.01). The median European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) measure was slightly higher in CMVD patients (3.5 [interquartile range 2.2-5.7]) compared to those with myxomatous disease (2.6 [interquartile range 1.5-4.2], P < 0.01). However, the observed mortality in the CMVD group was 3-4 times higher than predicted, whereas in the myxomatous group it was consistent with predicted values. CONCLUSIONS: CMVD defines a high-risk surgical population with substantial baseline cardiovascular morbidity and markedly elevated postoperative mortality and complication rates that were substantially underestimated by EuroSCORE II emphasizing the need for refined risk prediction models and individualized management strategies in this subset of patients.
RESUMEN
BACKGROUND: Comprehensive knowledge of the clinical presentation, contemporary management, and outcomes on "all-comer" patients referred for mitral valve surgery (MVS) are critical to evaluate current practice and adherence to guidelines, understand selection biases, and inform key stakeholders on quality improvement. METHODS: MITRACURE is a large international retrospective registry of consecutive adult patients who underwent isolated or combined MVS for mitral regurgitation (MR) in France or Canada in 2019 with in-depth clinical and echocardiographic characterization. Patients operated on for isolated mitral stenosis or who had a prior mitral valve intervention were excluded. Data were obtained from detailed chart abstraction and were site reported. RESULTS: In 2019, 3522 patients underwent MVS (48% combined) across 40 centers (88±46 MVSs/center, median 80, interquartile [51-131]). Mean age was 65±12 years, and 35% were women. The most common MR etiology was myxomatous (61%), followed by functional (9%), infective endocarditis (9%), and rheumatic disease (7%). MR quantification was performed in only 43%. Advanced clinical presentation was common: 43% were in New York Heart Association class III/IV, 30% exhibited congestive heart failure, 47% were on diuretics, 22% had atrial fibrillation/flutter, 35% presented with reduced ejection fraction, and 22% had pulmonary hypertension (≥50 mm Hg). Most patients were symptomatic or presented with class I/IIa indication for intervention, and an early intervention was performed only in 3% of patients. The repair rate was 62% overall and 80% in myxomatous disease. In-hospital mortality was 4.5% overall but 2.3% in patients with myxomatous MR (1.8% isolated, 3.1% combined). CONCLUSIONS: MITRACURE provides a contemporary, multicenter, "real-world" picture of the clinical presentation, management, and in-hospital outcomes of MVS for MR in two Western countries. Patients were often referred late in the disease process, with few patients undergoing early intervention. The higher mortality and lower repair rates reported may be more reflective of an unselected MR patient population but have room for improvement. Our results underline the need to develop strategies to improve management and outcomes of patients with MR.
Asunto(s)
Insuficiencia de la Válvula Mitral , Válvula Mitral , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Canadá , Francia/epidemiología , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Sistema de Registros , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Cardiac transthyretin amyloidosis (ATTR-CM) is a life-threatening cardiomyopathy. Tafamidis has been demonstrated to be an effective treatment. Our aim was to analyze clinical characteristics and survival of patients with ATTR-CM aged ≥80 years diagnosed after November 2018, treated with tafamidis 80/61 mg, and compare them with a non-treated group diagnosed before that date. METHODS: Data from the two groups were extracted from the Healthcare European Amyloidosis Registry (HEAR). Propensity score matching was used to adjust for baseline differences between the groups. Kaplan-Meier survival curves and Cox regression analyses were applied to assess survival outcomes. RESULTS: Out of 1380 patients, 1194 were treated with tafamidis 80/61 mg. Treated patients were significantly less severe at baseline, with a lower occurrence of NYHA class III-IV compared to the untreated group (24 vs. 46 %, p < 0.001). The median NT-proBNP at baseline was lower in the treated group (2330 vs. 4854 pg/ml, p < 0.001), as was the average level of high-sensitivity troponin T (55 vs. 74 ng/ml, p < 0.001), and the interventricular septal thickness (16 vs. 18 mm, p < 0.001). The 3-year survival rate for treated patients was 57 %, and 40 % for untreated patients. In the treated group, the 3-year survival rate was 68 % for patients aged 80-85 years and 58 % for those over 85 years. Survival rates were confirmed after propensity score analyses. CONCLUSIONS: This study demonstrates that tafamidis provides significant survival benefits for elderly patients with ATTR-CM, even in those over 85 years old. The findings emphasize the importance of early diagnosis and treatment.
Asunto(s)
Neuropatías Amiloides Familiares , Benzoxazoles , Cardiomiopatías , Sistema de Registros , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Neuropatías Amiloides Familiares/tratamiento farmacológico , Neuropatías Amiloides Familiares/mortalidad , Neuropatías Amiloides Familiares/diagnóstico , Benzoxazoles/uso terapéutico , Benzoxazoles/administración & dosificación , Cardiomiopatías/tratamiento farmacológico , Cardiomiopatías/mortalidad , Europa (Continente)/epidemiología , Estudios de Seguimiento , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estudios de Casos y ControlesRESUMEN
BACKGROUND: Cardiac amyloidosis (CA) is a rare disease that can lead to poor quality of life, conduction disorders, arrhythmia, heart failure, and even death. Fortunately, specific treatments that can modify the natural history of the disease and the disease outcomes are now available. However, data on the prevailing patient management procedures and long-term outcomes of CA are scarce. OBJECTIVE: The Healthcare Amyloidosis European Registry (HEAR) is 34-centre registry initiated in France and structured for European expansion through the French Clinical Research Infrastructure Network's Group for Research on Amyloidosis and Care Excellence and the European Clinical Research Infrastructure Network. We expect to include 8500 patients between January 2021 and December 2027. METHODS: The HEAR has been designed to capture detailed demographic, clinical, laboratory, imaging, and therapeutic data from both suspected and confirmed cases of all cardiac amyloidosis subtypes, including wildtype transthyretin amyloidosis, variant transthyretin amyloidosis, light-chain amyloidosis, and rarer forms. This comprehensive approach has been designed to (i) improve our understanding of real-world diagnostic pathways, treatment practices, and patient outcomes and (ii) incorporate patient-centred innovations. To enhance the patient-centred nature of the registry, patient-reported outcome measures (PROMs) will be systematically collected. CONCLUSIONS: By addressing diagnostic pathways, real-world management and PROMs and by applying technological innovations and European scalability, the next-generation HEAR is establishing itself as a valuable resource for clinical research, public health interventions, and better patient care in the field of CA.
Asunto(s)
Amiloidosis , Sistema de Registros , Humanos , Amiloidosis/epidemiología , Europa (Continente)RESUMEN
BACKGROUND: Early access experience in France with tafamidis meglumine, a selective transthyretin stabilizer for transthyretin-related amyloidosis cardiomyopathy (ATTR-CM), following transthyretin-related amyloidosis (ATTR) polyneuropathy approval and positive ATTR-ACT study results. AIM: To describe the characteristics and clinical outcomes for patients in the French ATTR-CM tafamidis meglumine early access programme (28 Nov 2018 to 01 Jun 2021). METHODS: Patients with confirmed ATTR-CM received tafamidis meglumine 20mg/day or 80mg/day. Demographic and clinical data were collected prospectively until patients discontinued treatment or died, or the programme ended. RESULTS: Overall, 222 physicians from 126 centres enrolled 2788 patients. The median age was 82years, 81.6% were male and New York Heart Association severity was class I for 12.8%, class II for 60.1% and class III for 27.0%. Overall, 1943 (74.6%) had genetic testing, and the results were available at tafamidis start for 1208 (62.2%) patients: 995 (82.4%) had wild-type ATTR and 213 (17.6%) had hereditary ATTR. Most patients started treatment≤12months after diagnosis (88.3%): 2268 (81.3%) at 20mg/day, with 401 (17.7%) increasing to 80mg/day. Median follow-up duration was 11.8months. New York Heart Association class improved or remained stable for 1299 (77.6%), whereas 376 (22.4%) worsened between inclusion and last follow-up. Among patients initiated at 80mg, 297 (81.1%) improved or remained stable and 69 (18.9%) worsened. New York Heart Association class progression did not vary with age. The 18-month survival rates were 89.8% (95% confidence interval: 87.0-92.0) among patients aged<80years, and 86.5% (95% confidence interval: 83.9-88.7) among those aged≥80years. CONCLUSIONS: Early tafamidis meglumine access was given to 2788 patients with ATTR-CM. New York Heart Association class progression and survival were consistent with previously published data.
RESUMEN
BACKGROUND: Many studies explored the impact of ventilation during cardiopulmonary bypass (CPB) period with conflicting results. Functional residual capacity or End Expiratory Lung Volume (EELV) may be disturbed after cardiac surgery but the specific effects of CPB have not been studied. Our objective was to compare the effect of two ventilation strategies during CPB on EELV. METHODS: Observational single center study in a tertiary teaching hospital. Adult patients undergoing on-pump cardiac surgery by sternotomy were included. Maintenance of ventilation during CPB was left to the discretion of the medical team, with division between "ventilated" and "non-ventilated" groups afterwards. Iterative intra and postoperative measurements of EELV were carried out by nitrogen washin-washout technique. Main endpoint was EELV at the end of surgery. Secondary endpoints were EELV one hour after ICU admission, PaO2/FiO2 ratio, driving pressure, duration of mechanical ventilation and post-operative pulmonary complications. RESULTS: Forty consecutive patients were included, 20 in each group. EELV was not significantly different between the ventilated versus non-ventilated groups at the end of surgery (1796 ± 586 mL vs. 1844 ± 524 mL, p = 1) and one hour after ICU admission (2095 ± 562 vs. 2045 ± 476 mL, p = 1). No significant difference between the two groups was observed on PaO2/FiO2 ratio (end of surgery: 339 ± 149 vs. 304 ± 131, p = 0.8; one hour after ICU: 324 ± 115 vs. 329 ± 124, p = 1), driving pressure (end of surgery: 7 ± 1 vs. 8 ± 1 cmH2O, p = 0.3; one hour after ICU: 9 ± 3 vs. 9 ± 3 cmH2O), duration of mechanical ventilation (5.5 ± 4.8 vs 8.2 ± 10.0 h, p = 0.5), need postoperative respiratory support (2 vs. 1, p = 1), occurrence of pneumopathy (2 vs. 0, p = 0.5) and radiographic atelectasis (7 vs. 8, p = 1). CONCLUSION: No significant difference was observed in EELV after cardiac surgery between not ventilated and ventilated patients during CPB.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Respiración Artificial , Adulto , Humanos , Respiración Artificial/efectos adversos , Puente Cardiopulmonar/efectos adversos , Mediciones del Volumen Pulmonar/métodos , Pulmón , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Complicaciones Posoperatorias/etiología , Periodo Perioperatorio/efectos adversosRESUMEN
Background: The coronavirus disease 2019 (COVID-19) was first identified in December 2019 and is currently still a public health issue affecting millions of people worldwide. Heart failure patients are known to be at higher risk of morbidity and mortality in this case. Yet, few data exist concerning COVID-19 among patients with a left ventricular assistance device, and even less among those with a total artificial heart (TAH). Case summary: A 27-year-old man with Marfan syndrome underwent prophylactic ascending aorta replacement. Shortly after surgery completion, he developed refractory cardiogenic shock with biventricular dysfunction leading to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation. In the context of no appropriate eligible donor during the following 10 days while waiting on the heart transplantation list, the patient was scheduled for a TAH as a bridge to transplantation. Meanwhile, he developed an acute respiratory distress syndrome secondary to SARS-CoV-2. The patient was successfully treated with corticosteroids, prone positioning and mechanical ventilation, and heart transplantation occurred 5 weeks after COVID-19 onset. Discussion: Here, we report the first case of a patient presenting with COVID-19 infection following TAH implantation in a bridge to transplantation. We highlight that (i) cardiogenic shock patients simultaneously infected by COVID-19 should be treated instantly with all-time available technology to ensure best outcomes, including TAH and prone positioning, (ii) heart transplantation safety 5 weeks after COVID-19 onset.
RESUMEN
BACKGROUND: Transcatheter closure of a symptomatic prosthetic paravalvular leak (PVL) is feasible, but there is presently no conclusive evidence to show consistent efficacy. We aimed to identify predictors of clinical success after transcatheter PVL closure. METHODS: Consecutive patients referred to 24 European centers for transcatheter PVL closure in 2017 to 2019 were included in a prospective registry (Fermeture de Fuite ParaProthétique, FFPP). Clinical success was absence of any of the following within 1 month: re-admission for heart failure, blood transfusion, open-heart valvular surgery, and death. RESULTS: We included 216 symptomatic patients, who underwent 238 percutaneous PVL closure procedures on the mitral (64.3%), aortic (34.0%), or tricuspid (1.7%) valve. Symptoms were heart failure, hemolytic anemia, or both in 48.9%, 7.8%, and 43.3% of patients, respectively. One, 2, and 3 leaks were treated during the same procedure in 69.6%, 26.6%, and 3.8% of patients, respectively. The PVL was pinpoint or involved 1/8 or 1/4 of the valve circumference in 18.6%, 52.4%, and 28.1% of cases, respectively. The most frequently used devices were the Vascular Plug 3, Ventricular Septal Defect Occluder, Vascular Plug 2, and Paravalvular Leak Device (45.0%, 16.6%, 14.2%, and 13.6% of cases, respectively). Successful device(s) implantation with leak reduction to ≤grade 2 was obtained in 85.0% of mitral and 91.4% of aortic procedures, respectively (P=0.164); with major periprocedural adverse event rates of 3.3% and 1.2%, respectively (P=0.371); and clinical success rates of 70.3% and 88.0%, respectively (P=0.004). By multivariate analysis, technical failure, mechanical valve, and hemolytic anemia were independently associated with absence of clinical success (odds ratios [95% CIs], 7.7 [2.0-25.0]; P=0.002; 3.6 [1.1-11.1]; P=0.036; and 3.7 [1.2-11.9]; P=0.025; respectively). CONCLUSIONS: Transcatheter PVL closure is efficient and safe in symptomatic patients but is associated with a lower clinical success rate in patients with hemolysis and/or a mechanical valve. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifiers: NCT05089136.
Asunto(s)
Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Prótesis Valvulares Cardíacas/efectos adversos , Resultado del Tratamiento , Sistema de Registros , Insuficiencia Cardíaca/etiología , Cateterismo Cardíaco , Falla de PrótesisRESUMEN
We conducted a single-center retrospective study to assess cardiovascular (CV) toxicity and treatment discontinuation for CV toxicity in diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma (FL) patients treated with immunochemotherapy (R-CHOP-like). Between 2006 and 2017, 433 patients were included (DLBCL: n = 345, FL: n = 88). The median age was 63 years (50-73). We defined three types of CV toxicity: early-onset cardiovascular toxicity (the event occurred within 6 months following treatment start); subacute toxicity (the event occurred between 6 months and 1 year after treatment start) and late toxicity (the event occurred 1 year or more after treatment start). Forty-eight (11.1%) patients experienced at least one anthracycline-related CV event. Seven patients experienced treatment discontinuation due to CV toxicity. Early-onset and subacute cardiac events were primarily acute heart failure (34.3%) and atrial fibrillation (28.6%). History of ischemic heart disease (p = 0.02) and valvular heart disease (p = 0.03) were associated with a higher risk of anthracycline-related CV event occurrence.
Asunto(s)
Linfoma Folicular , Linfoma de Células B Grandes Difuso , Linfoma no Hodgkin , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Linfoma no Hodgkin/tratamiento farmacológico , Doxorrubicina/uso terapéutico , Rituximab , Linfoma Folicular/tratamiento farmacológico , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Vincristina/uso terapéutico , Ciclofosfamida/uso terapéutico , Prednisona/uso terapéutico , Antraciclinas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéuticoRESUMEN
BACKGROUND: The Minto pharmacokinetic model is used for target-controlled infusion of remifentanil. The reliability of this model has never been evaluated during normothermic cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to assess the predictive performance of the model during CPB to determine its reliability during cardiac surgery. METHODS: This was a single-centre observational study. Arterial blood samples were drawn at five time points: T1, after tracheal intubation; T2, immediately before CPB; T3, 10 min after starting CPB; T4, 45 min after starting CPB; T5, 10 min after weaning off CPB. Prediction error (PE) and absolute prediction error (APE) were calculated for each sample and used to determine median prediction error (MDPE) and median absolute prediction error (MDAPE) per patient. Risk factors for APE >30% were assessed using multivariable analysis. Results are presented as medians with inter-quartile ranges. RESULTS: Fifty-eight patients with 283 blood samples (110 during CPB) were included. In the pre-CPB period, MDPE and MDAPE were -17.3 [-32.9 to 2.3] and 24.6 [12-37.7]%, whereas during CPB, they were -1.8 [-15.6 to 11.1] and 14.0 [6.74-27.1]%, respectively. There was no statistically significant difference between measured and predicted remifentanil plasma concentrations during CPB. Age, preoperative albumin concentrations, temperature, and haemodilution were not independently associated with MDAPE >30%. CONCLUSIONS: The Minto model accurately predicts plasma remifentanil concentrations during cardiac surgery with CPB. CLINICAL TRIAL REGISTRATION: 2017-A03153-50.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Puente Cardiopulmonar , Puente Cardiopulmonar/métodos , Humanos , Infusiones Parenterales , Remifentanilo , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: The ACURATE neo™ transcatheter heart valve (Boston Scientific, Marlborough, Massachusetts) is predominantly implanted via femoral access. Transcarotid use of this prothesis has never been reported. CASE PRESENTATION: We present the case of an 89-year-old woman referred to us for a transcatheter aortic valve replacement (TAVR). After apparatus imaging of the aortic annulus and the peripheral vascular pathway, the heart team was confronted with a triple challenge: (i) The preferable choice of a self-expanding valve because of a small aortic annulus in an obese woman. (ii) Gaining favorable access to the coronary ostia, considering multiple recent coronary stenting. (iii) Utilizing an alternative arterial access because of iliac and femoral severely calcified stenosis. Implanting the ACURATE neo™ transcatheter heart valve (THV) via carotidal access allowed us to overcome these challenges. The procedure was performed successfully without any short-term complications. CONCLUSION: We report the first case of implantation of an ACURATE neo™ transcatheter heart valve (Boston Scientific, Marlborough, Massachusetts) via the right common carotid artery.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Arteria Carótida Común/cirugía , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano de 80 o más Años , Femenino , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentaciónRESUMEN
PURPOSE: To assess myocardial extracellular volume fraction (ECV) measurement provided by a single-source dual-energy computed tomography (SSDE-CT) acquisition added at the end of a routine CT examination before transcatether aortic valve implantation (TAVI) compared to cardiac magnetic resonance imaging (MRI). MATERIALS AND METHODS: Twenty-one patients (10 men, 11 women; mean age, 86±4.9 years [SD]; age range: 71-92 years) with severe aortic stenosis underwent standard pre-TAVI CT with additional cardiac SSDE-CT acquisition 7minutes after intravenous administration of iodinated contrast material and myocardial MRI including pre- and post-contrast T1-maps. Myocardial ECV and standard deviation (σECV) were calculated in the 16-segments model. ECV provided by SSDE-CT was compared to ECV provided by MRI, which served as the reference. Analyses were performed on a per-segment basis and on a per-patient involving the mean value of the 16-segments. RESULTS: ECV was slightly overestimated by SSDE-CT (29.9±4.6 [SD] %; range: 20.9%-48.3%) compared to MRI (29.1±3.9 [SD] %; range: 22.0%-50.7%) (P<0.0001) with a bias and limits of agreement of +2.3% (95%CI: -16.1%-+20.6%) and +2.5% (95%CI: -2.1%-+7.1%) for per-segment and per-patient-analyses, respectively. Good (r=0.81 for per-segment-analysis) to excellent (r=0.97 for per-patient-analysis) linear relationships (both P<0.0001) were obtained. The σECV was significantly higher at SSDE-CT (P<0.0001). Additional radiation dose from CT was 1.89±0.38 (SD) mSv (range: 1.48-2.47 mSv). CONCLUSION: A single additional SSDE-CT acquisition added at the end of a standard pre-TAVI CT protocol can provide ECV measurement with good to excellent linear relationship with MRI.
Asunto(s)
Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Femenino , Humanos , Masculino , Miocardio , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Cardiac stiffness is a marker of diastolic function with a strong prognostic significance in many heart diseases that is not measurable in clinical practice. This study investigates whether elastometry, a surrogate for organ stiffness, is measurable in the heart using ShearWave Imaging. METHODS: In 33 anesthetized patients scheduled for cardiac surgery, ShearWave imaging was acquired epicardially using a dedicated ultrasound machine on the left ventricle parallel to the left anterior descending coronary artery in a loaded heart following the last cardiac beat. Cardiac elastometry was measured offline using the Young modulus with customized software. RESULTS: Overall, the ejection fraction was 61 ± 10%. E/A and E/e' ratios were 1.0 ± 0.5 and 10.5 ± 4.1, respectively. Cardiac elastometry averaged 15.3 ± 5.3 kPa with a median of 18 kPa. Patients with high elastometry >18 kPa were older (P = .04), had thicker (P = .02) but smaller LV (P = .004), had larger left atria (P = .05) and a higher BNP level (P = .04). We distinguished three different transmural elastometry patterns: higher epicardial, higher endocardial, or uniformly distributed elastometry. CONCLUSION: Elastometry measurement was feasible for the human heart. This surrogate for cardiac stiffness dichotomized patients with low and high elastometry, and provided three different phenotypes of transmural elastometry with link to diastolic function.
Asunto(s)
Disfunción Ventricular Izquierda , Diástole , Ecocardiografía , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Proyectos PilotoRESUMEN
Rationale: Pulmonary hypertension (PH) associated with neurofibromatosis type 1 (NF1) is a rare and largely unknown complication of NF1.Objectives: To describe characteristics and outcomes of PH-NF1.Methods: We reported the clinical, functional, radiologic, histologic, and hemodynamic characteristics, response to pulmonary arterial hypertension (PAH)-approved drugs, and transplant-free survival of patients with PH-NF1 from the French PH registry.Measurements and Main Results: We identified 49 PH-NF1 cases, characterized by a female/male ratio of 3.9 and a median (minimum-maximum) age at diagnosis of 62 (18-82) years. At diagnosis, 92% were in New York Heart Association functional class III or IV. The 6-minute-walk distance was 211 (0-460) m. Pulmonary function tests showed low DlCO (30% [12-79%]) and severe hypoxemia (PaO2 56 [38-99] mm Hg). Right heart catheterization showed severe precapillary PH with a mean pulmonary artery pressure of 45 (10) mm Hg and a pulmonary vascular resistance of 10.7 (4.2) Wood units. High-resolution computed tomography images revealed cysts (76%), ground-glass opacities (73%), emphysema (49%), and reticulations (39%). Forty patients received PAH-approved drugs with a significant improvement in functional class and hemodynamic parameters. Transplant-free survival at 1, 3, and 5 years was 87%, 54%, and 42%, respectively, and four patients were transplanted. Pathologic assessment showed nonspecific interstitial pneumonia and major pulmonary vascular remodeling.Conclusions: PH-NF1 is characterized by a female predominance, a low DlCO, and severe functional and hemodynamic impairment. Despite a potential benefit of PAH treatment, prognosis remains poor, and double-lung transplantation is an option for eligible patients.
Asunto(s)
Hipertensión Pulmonar/tratamiento farmacológico , Hipertensión Pulmonar/fisiopatología , Hipertensión Pulmonar/cirugía , Neoplasias Pulmonares/fisiopatología , Neurofibromatosis 1/complicaciones , Neurofibromatosis 1/genética , Neurofibromina 1/genética , Adolescente , Adulto , Femenino , Francia , Humanos , Hipertensión Pulmonar/etiología , Trasplante de Pulmón/métodos , Masculino , Persona de Mediana Edad , Fenotipo , Pronóstico , Adulto JovenRESUMEN
AIMS: The aim of this study was to assess the efficacy and safety of the Occlutech Paravalvular Leak Device (PLD) for the percutaneous closure of paravalvular leaks (PVL). METHODS AND RESULTS: Patients with PVL were enrolled at 21 sites from nine countries. Indications for PVL closure were heart failure and/or haemolytic anaemia. Endpoint measures were changes in PV regurgitation grade, NYHA class and requirement for haemolysis-related transfusion. One-hundred and thirty-six patients with mitral (67.6%) or aortic (32.4%) leaks were included (mean age 66.7 years, 58% male); 31% had multiple PVLs. The proportion of patients with NYHA Class III/IV decreased from 77.3% at baseline to 16.9% at latest follow-up. The proportion of patients with need for haemolysis-related blood transfusion decreased from 36.8% to 5.9% and from 8.3% to 0% for ML patients and AL patients, respectively. All-cause mortality was 7.4%. Complications included interference with valve leaflets (0.7%), transient device embolisation (percutaneously solved) (0.7%), late device embolisation (0.7%), recurrent haemolytic anaemia (2.2%), new-onset haemolytic anaemia (0.7%), valve surgery (2.2%), need for repeat closure (0.7%), complications at femoral puncture site (0.7%) and arrhythmias requiring treatment (4.4%). CONCLUSIONS: PVL closure with the Occlutech PLD demonstrated a high success rate associated with significant clinical improvement and a relatively low rate of serious complications. Visual summary. PVL characteristics, leak approach, device types and midterm procedural and clinical outcomes of percutaneous paravalvular leak closure with the Occlutech® PLD. Transcatheter PVL closure with the specifically designed PLD was demonstrated to be effective with a relatively low rate of major complications. Procedural success for ML and AL closure was high with a low rate of residual or recurrent leaks. Significant improvement of NYHA class, and reduction of haemolytic anaemia and transfusion dependency were achieved.
Asunto(s)
Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anciano , Cateterismo Cardíaco , Femenino , Humanos , Masculino , Falla de Prótesis , Resultado del TratamientoRESUMEN
Multi-organ AL amyloidosis is a therapeutic challenge because of light chain deposits severely damaging the function of concerned organs. Cardiac involvement, which leads to concentric hypertrophy of both ventricles, is particularly severe and leads to poor prognosis regardless of combination chemotherapy. This case pinpoints the relevance of combining clinical, histological, and echocardiographic information in the management of this complex and life-threatening disease.
RESUMEN
OBJECTIVES: The aim of this study was to assess the incidence, prognostic impact, and predictive factors of readmission for congestive heart failure (CHF) in patients with severe aortic stenosis treated by transcatheter aortic valve replacement (TAVR). BACKGROUND: TAVR is indicated in patients with severe symptomatic aortic stenosis in whom surgery is considered high risk or is contraindicated. Readmission for CHF after TAVR remains a challenge, and data on prognostic and predictive factors are lacking. METHODS: All patients who underwent TAVR from January 2010 to December 2014 were included. Follow-up was achieved for at least 1 year and included clinical and echocardiographic data. Readmission for CHF was analyzed retrospectively. RESULTS: This study included 546 patients, 534 (97.8%) of whom were implanted with balloon-expandable valves preferentially via the transfemoral approach in 87.8% of cases. After 1 year, 285 patients (52.2%) had been readmitted at least once, 132 (24.1%) for CHF. Patients readmitted for CHF had an increased risk for death (p < 0.0001) and cardiac death (p < 0.0001) compared with those not readmitted for CHF. On multivariate analysis, aortic mean gradient (hazard ratio [HR]: 0.88; 95% confidence interval [CI]: 0.79 to 0.99; p = 0.03), post-procedural blood transfusion (HR: 2.27; 95% CI: 1.13 to 5.56; p = 0.009), severe post-procedural pulmonary hypertension (HR: 1.04; 95% CI: 1.00 to 1.07; p < 0.0001), and left atrial diameter (HR: 1.47; 95% CI: 1.08 to 2.01; p = 0.02) were independently associated with CHF readmission at 1 year. CONCLUSIONS: Readmission for CHF after TAVR was frequent and was strongly associated with 1-year mortality. Low gradient, persistent pulmonary hypertension, left atrial dilatation, and transfusions were predictive of readmission for CHF.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Insuficiencia Cardíaca/epidemiología , Readmisión del Paciente , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Valvuloplastia con Balón/efectos adversos , Causas de Muerte , Distribución de Chi-Cuadrado , Ecocardiografía , Femenino , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Hipertensión Pulmonar/epidemiología , Hipertensión Pulmonar/fisiopatología , Incidencia , Estimación de Kaplan-Meier , Masculino , Análisis Multivariante , Oportunidad Relativa , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del TratamientoRESUMEN
OBJECTIVES: To compare image quality and radiation dose of pre-transcatheter aortic valve implantation (TAVI) aortoiliofemoral CT angiography (AICTA) provided by standard vs. dual-energy mode with reduced iodine load protocols. METHODS: One hundred and sixty-one patients underwent a two-step CTA protocol before TAVI including cardiac CTA with injection of 65 mL of iodinated contrast agent (ICA), immediately followed by AICTA. From this second acquisition, the following three different patient groups were identified: Group 1: 52 patients with standard AICTA (60 mL ICA, 100 kVp, mA automodulation); Group 2: 48 patients with dual-energy AICTA with 50 % iodine load reduction (30 mL ICA, fast kVp switching, 600 mA); Group 3: 61 patients with an identical protocol to Group 2, but exposed to 375 mA. The qualitative/subjective image quality (13-point score) and quantitative/objective image quality (contrast attenuation and image noise) were evaluated. The radiation dose was recorded. RESULTS: There was no significant difference in non-diagnostic images between the three protocols. Contrast attenuation, signal-to-noise ratio and contrast-to-noise ratio were significantly higher, whereas noise was significantly lower in the standard protocol (all P < 0.05). The radiation dose was lower in the dual-energy protocol at 375 mA (P < 0.05). CONCLUSIONS: Dual-energy AICTA before TAVI results in a reduction of iodine load while maintaining sufficient diagnostic information despite increased noise. KEY POINTS: ⢠Dual-energy AICTA before TAVI results in a 50 % reduction of iodine load. â¢The reduction of iodine load maintains sufficient image quality despite increased noise. ⢠Using 375 mA in dual-energy mode results in a reduction of radiation dose. ⢠A high tube current setting (600 mA) should be used in overweight patients.
Asunto(s)
Angiografía/métodos , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Aumento de la Imagen , Yohexol , Tomografía Computarizada Multidetector/métodos , Reemplazo de la Válvula Aórtica Transcatéter , Anciano de 80 o más Años , Aorta Abdominal/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Medios de Contraste/administración & dosificación , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Arteria Ilíaca/diagnóstico por imagen , Inyecciones Intraarteriales , Yodo , Yohexol/administración & dosificación , Masculino , Periodo Preoperatorio , Curva ROC , Dosis de Radiación , Reproducibilidad de los Resultados , Estudios Retrospectivos , UltrasonografíaRESUMEN
BACKGROUND: Only 50% of patients with aortic stenosis (AS) and low ejection fraction (EF) improve their contractility after surgical aortic valve replacement (AVR). Long-term prognosis of these patients is strongly correlated to EF recovery after the surgery. The aim of this study was to compare the postoperative left ventricular function recovery in patients with severe AS and reduced EF after AVR and transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: Twenty-one patients undergoing AVR for severe AS (<1 cm²) and reduced EF (<45%) were echocardiographically compared with 31 patients treated with TAVI by conventional and two-dimensional (2D) strain method. TAVI patients were older (83 ± 6 vs. 74 ± 13 years, P < 0.001), had more comorbidities (Euroscore 26 ± 15% vs. 16 ± 12%, P < 0.001) and no differences in ischemic heart disease (16.1% vs. 9.5%, P = 0.39). EF was similar in both groups at baseline. Aortic valve area significantly increased (P = 0.01) while pressure gradient decreased (P = 0.009) after both procedures but TAVI was associated with a better EF recovery compared with AVR at day 7. Regional function assessed by radial 2D strain increased in TAVI group but was transiently deteriorated in AVR patients (P < 0.05). Longitudinal as well as circumferential 2D strain progressively increased at follow-up in both groups (P < 0.05). EF was similar in both groups at 3-month follow-up. CONCLUSION: In patients with severe AS and reduced EF, TAVI is associated with faster and better recovery of LV function compared with AVR.